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mental health mondays :: getting off

this is your brain off drugs
there's so much discussion about how psychiatric medication is over-prescribed, whereas non-pharmaceutical methods of treating depression and anxiety are neglected. it can be difficult to maneuver through the morass of information on who should be taking these medications and who shouldn't, plus there's conflicting information on how effective any of them are even if you do need them. the bottom line seems to be the same as it is with virtually everything in this field: brains are so unbelievably complicated that it's difficult to predict exactly what's going to happen with any individual until you try.

i do share the suspicion that a lot of doctors are a little too quick to prescribe pills when someone says they're suffering. i'd like to say that it's because people often wait to see a doctor until they're really suffering, so the doctor just wants to address the problem as quickly as possible, but given that antidepressants and anti-anxiolytics are slow to reach their full effect, that's not very likely. i do think that given how brief standard doctors' appointments are, many professionals just aren't getting the detail they need to properly evaluate each patient. drugs are way easier than figuring out other lifestyle factors that might be affecting mood and therefore remain a first line of treatment.

there are lots of problems with this approach, but one of them is that it can be extremely difficult to tell when you're ready to stop taking such medications, which begets there is a tendency to let people just continue right on taking them ad nauseum. after all, if the meds are working, how can you tell when the underlying condition is gone? after all, there is evidence that even serious mental disorders can pass over time even without treatment. a lifelong mental disorder is the anomaly.

so it stands to reason that at some point, it will be time to consider reducing and/ or discontinuing your medication[s]. before i get into this, i'd just like to point out again that i'm not a professional. i'm an interested amateur who reads a lot on the subject, but nothing i say should be taken as gospel. it's well-meaning advice.



so you've decided to stop taking your medication...

or maybe your doctor has suggested it. either way, it's worth a shot. after all, every drug has residual effects and the scary fact is that with new drugs being developed all the time, we don't always know what the long term effects are going to be. and drugs cost money, although how much will vary substantially depending on where you live in the world. but before we get into what you should expect from this process, let's agree on some ground rules:

  1. always consult your doctor and/ or psychiatric professional: you needed their approbation to start taking the drugs, you should damn well have it going in the opposite direction. although some doctors are more pill-happy than others, most of them aren't going to give you a big argument if you're determined to stop. and if they do, you might want to pay attention to their reasoning.
  2. consider what your state of mind was before you were medicated and what diagnosis you received: although they can pass with time, the fact is that serious mental disorders like bipolar and schizophrenia are likely to require medication over at least the medium and quite possibly the long term and have the potential for far worse consequences if medications are removed. weigh the benefits versus the rewards. those who are depressed and/ or anxious because over specific issues, on the other hand, are far more likely to recover when those issues are addressed. 
  3. never go cold turkey: this is likely to be covered by point #1, but in case you have to wait a long time to see your doctor and get his/ her advice, stopping your medication to see what happens in the meantime is a terrible idea. remember that these drugs have changed the chemistry of your brain and very few of them can just be cut off. they will remain in your body for a certain period of time, but take them away and your brain will start doing all sorts of things in order to compensate for the changes. you can easily end up in worse shape than ever. 

so now that we've agreed on that, let's look at what you might expect in terms of the discontinuation process from a few of the most popular drugs. i'm sticking to antidepressant and anti-anxiety drugs [with one exception]. i've tried to pick medications that are representative of a certain class of drugs and which are also the most commonly prescribed of their category. if there are any that you'd like to know about that i haven't covered, don't hesitate to ask.

xanax [alprazolam] :: the most commonly prescribed drug for anxiety should always be a temporary solution. it's addictive, as all benzodiazepines are, but it's an especially powerful benzo, which means that withdrawal can be worse than for most. benzodiazepines are mild anti-convulsants, so it shouldn't come as a surprise that the biggest risk is that your brain will backfire and you'll have seizures. these are a medical emergency and should be treated as such, which means that if it happens, you need to get your ass to the hospital. that said, there are loads of symptoms that are associated with benzo withdrawal, which can bear a creepy similarity to withdrawal from alcohol or illegal drugs, which just goes to show how arbitrary the line between forbidden and prescription is. what's worse is that withdrawal symptoms can persist for a year after the drug is cleared from the system.

because it relaxes the body, some level of rebound insomnia should be expected. likewise, you may feel achy, antsy and irritable as the calming influence of the drug is withdrawn. if you're doing it properly, these should fall into the category of annoying but manageable. you may also get tachycardia as your heart makes adjustments. needless to say, if this is frequent or disruptive, you should seek treatment. 

cessation tips :: proceed slowly. lower your dosage gradually and, as the dosage gets lower, ask your doctor to switch you to a longer-acting drug within the family. valium [diazepam] is a decent option, because it is both milder in effect and has a longer half life. longer half-life = gentler withdrawal.

alcohol is a big no-no [why are you drinking alcohol and taking xanax to begin with?], because it's been shown to decrease the chances of successful withdrawal. because you'll already be more prone to anxiety, and it pains me to say this, you'll also want to be very careful with anything caffeinated. certain antibiotics are also problematic, so make sure that all the medical professionals you deal with have all the information.

lexapro [escitalopram] :: one of the always popular ssri [selective serotonin reuptake inhibitor] class for a reason. it has few side effects and is one of the easiest psychiatric meds to discontinue. it also comes in a liquid version, so if you switch to that, you have a lot of control over how slowly you lower your dosage. honestly, though, the research that i've done points to relatively few issues with a gradual discontinuation. the drug has a long half life, which, as mentioned above, makes it easier. this is probably a good option if you are experiencing acute depression/ anxiety, but otherwise haven't had a lot of issues with mental health, simply because it is easier to retreat once you feel you might be getting back to your old self. also, patients have rated this as one of the easiest mental health medications to take, meaning they've had fewer side effects and at the same time one of the most effective. discontinuation can cause the jitters, headaches and numbness or tingling in the extremities. this is par for the course for any ssri medication and the symptoms for lexapro aren't known to be particularly harsh.

cessation tips :: since it doesn't cause a lot of issues, there aren't any special steps you have to follow and the relatively long half life means that gradual reduction in dosage can take care of itself. however if you're having trouble adjusting, you can ask your doctor about changing your prescription to prozac [fluoxetine] in order to get you through the final stretch. this is a common way to get patients through the "home stretch" of ssri withdrawal.

desyrel [trazodone] :: i was kind of surprised to see that this one was among the most prescribed psychiatric medications in the united states, since it's not one that i've heard a lot about here in canada. it is newer, but not exactly brand new and chances are that if you get it prescribed, it's because you're suffering from anxiety or depression that keeps you from sleeping, because desyrel is known for one thing: knocking you the fuck out. you may feel happier for the three hours a day you're awake, but a lot of people prefer to get a little more out of life, which means that many are eager to move on from their desyrel experience. as you might expect, there's a good chance that discontinuation will give you rebound insomnia, but you also need to be prepared for some nasty shifts in mood. in particular, expect things to piss you off a lot more than they normally do.

cessation tips :: desyrel has a half-life of between seven and ten hours, depending on whether you're taking the immediate or slow-release version. to give you some perspective, the half-life of the active metabolite of valium can be about a hundred hours. so take it really bloody slow with this one. your doctor will be able to help you make decisions about how slow is slow enough, but i've seen a ratio of reducing your dosage by 10% per week [assuming you can find pill sizes that will allow you to do that]. given the propensity for mood swings, you might want to see if you can take a few days off work and let those close to you know what you're doing, so that you don't end up having to explain things later to friends, family, coworkers or the police.

cymbalta [duloxetine] :: doctors have been going singing the praises of cymbalta because it helps with the reuptake of more than one neurotransmitter [serotonin, norepinephrine and dopamine are the "big three", although i've not seen anything to convince me that cymbalta does anything to affect dopamine], so your chances of it actually working are much better than if you're taking something that only affects serotonin. it's also known as the drug you're likely to get if physical pain is part of the symptoms you experience. and finally, it's known as the drug that people take because they hate effexor so very much. in 2009, prescriptions of cymbalta rose 237%, while those of effexor dropped 13%. clearly, cymbalta is doing more [or being recommended for more] than its older brother effexor, from whom it's taking market share.

one of the reasons that cymbalta has been getting preferential treatment is because of the horror stories of effexor withdrawal. if you've gone through this, i feel for you, because it's pretty harsh, particularly something called the "brain zaps", which i can't explain, but are immediately recognisable and remarkably well-named. many report muscle spasms, agitation and waves of anxiety that make your original problems look like nothing.

now the bad news: it turns out when people said cymbalta cessation was easier, what they meant was "this drug is new, so it has to be better, right?" no one had really looked at discontinuation symptoms in great detail and it turns out that cymbalta discontinuation is every bit as horrifying as effexor discontinuation. oh, and as a bonus, if cymbalta has been helping you manage pain [it's often prescribed for fibromyalgia], you can kiss that benefit goodbye in a hurry. oh, and some people claim that cymbalta withdrawal can trigger bipolar disorder in people who didn't previously have it. i haven't found a lot of science on that, but there is adequate evidence that the mood swings can be pretty severe, which could be confused with bipolar.

there is some good news, however: a lot of people don't get these symptoms and if you don't get them at first, chances are you'll be able to discontinue the medication without any serious issues. plus, of course, if you're thinking of discontinuing cymbalta, it means that you survived the often difficult process of starting to take it in the first place [pushing through the so-called "cymbalta wall"], so you're probably a tough cookie.

cessation tips :: i hate to put it this way, but think about whether or not you really want to stop taking cymbalta. the range and depth of symptoms can be pretty profound, to the point where even reducing the dosage can give you a first class ticket on the crazy train. if you do start to develop symptoms [you'll know quickly enough], you're going to have to choose whether or not to push through it or just deal with the fact that you're going to be on the drug for a long time.

unfortunately, the common approach of using a milder drug like prozac to mediate withdrawal doesn't work with snri's like cymbalta and effexor and there's little evidence that any other drugs can help either. your best bet is probably to fortify your diet with a lot of omega-3s [make sure you're getting ones with both ala and dha included- sources that only have ala like flax seed oil won't help with this particular problem] and as much vitamin d as you can handle taking. if pain is an issue, you should also try reducing your consumption of omega 6s and 9s, since those can increase inflammation. exercise a lot- chances are you'll have a lot of nervous energy anyway- and contact your doctor if things get really rough or weird.

seroquel [quetiapine] :: this is the exception i was talking about when i said there was one drug outside of the antidepressant/ anti-anxiety family i wanted to cover. seroquel is an anti-psychotic, which you'd think would mean that it was reserved for pretty serious cases, so i was sort of appalled to find out that it's among the most frequently prescribed crazy meds in north america and it seems to be getting more popular every year [88% increase in prescriptions in 2009]. does this mean that we're all going psychotic? well, no, because seroquel is increasingly prescribed to fight insomnia, which sounds to me like shooting heroin after you stub your toe, but no one asked me. [i wonder how willing people would be to take it if their doctors were actually telling them that it was an anti-psychotic and not just a sleep aid.]

of course, the reason that people take it for insomnia is that it works really, really, really well. it makes sense if you think about it- it's a drug designed to haul people down from psychotic mania, so it has to be calming.

if it has been prescribed to control mania, i'd recommend that you have a long conversation with your doctor about why you want to discontinue it. manias can be extremely dangerous and you want to make sure that they're kept under control.

however, if you're taking it to control depression and/ or anxiety, you might miss being awake and want to explore other options. and generally speaking, as long as you reduce somewhat gradually [you can go a little quicker with seroquel than with other drugs], there aren't a lot of extreme withdrawal symptoms. well, there is one. there's a theory [with some scientific backing, although it remains controversial] that seroquel withdrawal is "psychosis-mimetic", which is a fancy way of saying that it can make certain people psychotic even if they never were before. [and my opinion is that that alone would be reason enough not to take it unless you really feel it's necessary.]

that's not something that's common, however. what you should expect is some nausea, some rebound insomnia and some anxiety. there's also a tendency for some people to develop skin conditions like psoriasis or even gingivitis. these things are all temporary.

cessation tips :: withdrawing from seroquel can cause some fluctuations [and sudden drops] in blood pressure, so probably want to keep an eye on that [and be more careful than usual about standing up too quickly]. there can also be weird changes in blood sugar, which may not be a problem, but clearly if you have any predisposition to diabetes, you're going to want to keep an eye on that too. the mechanism of action of a lot of anti-psychotics, including seroquel, is not dissimilar to that of anti-histamines, so you may find that popping the occasional benadryl may help ease some discontinuation symptoms, especially inflammatory responses like rashes.  

whew! that was a long one but, i hope, informative. as i said, if there are any particular drugs you're curious about, please feel free to ask. 

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